Healing the Hip’s Rotator Cuff

Assessing Hip Bursitis and Tendinopathy

By Erik Dalton, PhD
[Myoskeletal Alignment Techniques]

The femoroacetabular joint is one of the largest, strongest, and most flexible joints in the body. As we walk, our hips give us power and stability, and when jumping, these ball-and-socket joints are able to withstand enormous impact. However, the hips and their supporting structures are often compromised due to aging, overuse, and traumatic events that cause the brain to reactively guard the area with spasm or pain. For decades, lateral hip pain has been blamed on injury to the fluid-filled bursa sacs covering the greater trochanter, thus the name trochanteric bursitis. Today, many manual therapists have come to realize certain cases of hip bursitis are actually due to wear and tear of the gluteus medius and minimus tendons, the iliotibial (IT) band, or both (Image 1).
Hip pain and instability due to gluteus medius, gluteus minimus, and IT band tendinosis may cause the client to walk or run with poor control, which creates friction and irritation of the trochanteric bursa. Researcher Thomas Bunker and his team were the first to compare this condition to rotator cuff bursitis, where the subacromial bursa becomes battered and inflamed as a result of underlying rotator cuff tendinopathy.1 He and others have called the gluteus medius and minimus tendons the rotator cuff of the hip.
Here, we’ll explore the myoskeletal approach to pain that affects the hip’s rotator cuff. Lateral hip pain includes at least three possible injury sites, so I’ll use the term greater trochanteric pain syndrome (GTPS) to describe this commonly seen condition. 

Testing for GTPS

I’ve found GTPS typically results from direct impact to the lateral hip, instability due to aging, prolonged single-leg weight bearing, or IT band irritation from repetitive movements. In these cases, the client typically complains of dull lateral hip pain, often radiating into the thigh. It’s not uncommon for clients to report increased hip pain at night or upon standing after sitting for an extended period of time.
During assessment, direct palpatory trochanter pressure, single-leg weight bearing for 30 seconds, or the resisted hip abduction test shown in Image 2 may aggravate the client’s pain. Together, these evaluations can help determine whether the client is suffering from trochanteric bursitis, gluteus medius tendinosis, or both. However, the hip de-rotation test demonstrated in Image 3 is still my favorite exam for reproducing hip symptoms in those with GTPS.

Posturofunctional Assessments

Performing a three-minute posturofunctional movement exam is another wonderful way to differentiate hip bursitis from underlying gluteus medius tendinopathy. The most important aspect to observe is the client’s seated and standing posture. Those with hip irritation tend to stand with the ipsilateral femoroacetabular joint slightly flexed. When seated, they slouch and lean to the uninvolved side. This posture takes pressure off the trochanteric bursa as the painful hip rests in a slightly less flexed position.
Faulty movement patterns observed during gait alert us to areas where the brain and body may not be communicating well. A classic example exists in those who present with a Trendelenburg gait (Image 4). This peculiar movement pattern is triggered by faulty sensory input, brain processing problems, or weak motor output. Physically, it manifests as weak abductors, valgus (knocked) knees, internally rotated femurs, and overpronated feet. In my experience, clients exhibiting Trendelenburg posture are more likely to experience GTPS due to increased IT band and gluteus medius compression as their tendons are forced back and forth across the inflamed bursa sac. However, we must remember these are just symptoms of an underlying central nervous system disorder.
Brain-based tests, such as single-leg standing, can help identify coordination and balance problems, whereas pain provocation tests work best to pinpoint strain patterns caused by reactive muscle guarding. Many people with GTPS experience generalized femoroacetabular stiffness and restricted range of motion. With these clients, I’ve had success using graded exposure hip-stretching techniques, such as the one demonstrated in Image 5, to restore alignment and function. Just remember, you must be patient when treating clients with chronic GTPS. This is not a quick-fix situation. The brain needs time to re-evaluate the new sensory input, determine the degree of threat, and allow more pain-free movement throughout the injured area.
Psychosocially, the client must be reminded their pain is not pathologic and that, in time, it will resolve itself. To help lower the client’s threat level, encourage them to make peace with their pain during the therapy process and to practice self-care in the form of novel proprioceptive exercises, such as mini-trampoline bouncing or dancing. In addition, make a special effort to assure the client they have come to the right place for help, and that by working together as a team, their hip symptoms will be relieved.


1. T. D. Bunker, C. N. Esler, and W. J. Leach, “Rotator-Cuff Tear of the Hip,” Journal of Bone and Joint Surgery 79, no. 4 (1997): 618–20.

Erik Dalton, PhD, is the executive director of the Freedom from Pain Institute. Educated in massage, osteopathy, and Rolfing, he has maintained a practice in Oklahoma City, Oklahoma, for more than three decades. For more information, visit www.erikdalton.com.